MEDICARE: LAURA GANCEDO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	G 74088	CA

General Provider Information

NPI Number	:	1689667404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA GANCEDO M.D.

Provider Business Mailing Address
First Line	:	6000 N FIGUEROA ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90042-4232
Country	:	US
Telephone Number	:	323-254-5221
Fax Number	:	323-254-4618

Provider Business Practice Location Address
First Line	:	4815 VALLEY BLVD STE C
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90032-3300
Country	:	US
Telephone Number	:	323-222-1134
Fax Number	:	323-221-4506

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	01/12/2012

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